At Blue MountainWellness, we care about you as a person. We are NOT here to judge. We are here to guide and support you. Our path to work together for sensible, maintainable, weight loss begins with honestly filling out this form. We are excited to start that journey with you!
Personal Contact Information
Marital Status
Single
Married
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Separated
Divorced
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How did you hear about us?
Facebook
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General Health and Wellness History
Are you currently under the care of a physician?
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No
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Are you taking any medications?
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Personal Health: (Check all that apply)
Stroke
Diabetes
High BP
Weight Problems
Depression
Ulcer
Heart Disease
Thyroid Issues
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Has your doctor advised you to lose weight?
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No
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Do you have any dietary restrictions?
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No
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Do you feel stressed?
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No
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Does your weight problem cause physical pain?
Yes
No
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Average Hours of Sleep per night
<1
1-3
3-6
6-8
8-10
>10
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Diet Information and History
Are you embarrassed by your weight or does it limit your desire to participate in activities?
Yes
No
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Psychological Impact of Your Weight Relationship with Food
Does your weight problem make you physically uncomfortable?
Yes
No
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Do you feel that food controls you?
Yes
No
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Does being overweight and unhealthy limit your activities?
Yes
No
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Do you binge eat?
Yes
No
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Do you suffer from uncontrollable cravings?
Yes
No
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Do you eat because of your emotions?
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No
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Do you eat between meals?
Yes
No
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Personal Goals
Please answer the following questions honestly so we can do our best to help you reach your goals. Check ALL areas of treatment that interest you:
Weight Loss
Cleansing and Detoxification
General Wellness
More Energy
Stress Reduction
Other
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Does your family support your weight loss efforts?
Yes
No
Unsure
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To what extent are you willing to commit to achieving better health?
Little
Moderate
Major
Extreme
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